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Durairaj T, Aparnavi P, Narayanan S, Mahantshetti S, Dhandapani S, Shanmugam J, Rathinamoorthy R, Kumar M. Utilization of modern menstrual methods and related unmet needs among college going women in Coimbatore district: a descriptive cross-sectional study. BMC Womens Health 2024; 24:78. [PMID: 38291382 PMCID: PMC10826201 DOI: 10.1186/s12905-024-02915-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Accepted: 01/19/2024] [Indexed: 02/01/2024] Open
Abstract
OBJECTIVES The primary objectives were to determine the proportion of modern menstrual method (MMM) users among college going women in Coimbatore district, Tamil Nadu; and to estimate the unmet needs associated with use of MMMs in comparison with other menstrual hygiene methods (MHMs). We also assessed the factors that determine MMM use among college going women. METHODS This was a descriptive cross-sectional study conducted among college going women in Coimbatore district, Tamil Nadu, India between October 2022 and January 2023 using a purpose predesigned, pretested, semi-structured proforma that included validated Menstrual Practice Needs Scale (MPNS-36). RESULTS Only 1.4% of the study participants used MMMs - menstrual cups (1.3%) and tampons (0.1%). Sanitary pads were the most common MHM of choice (96.3%); of which majority (98.6%) used disposable pads and more than half (50.4%) used non-biodegradable pads. Importantly, one in six (16.5%) were not aware of nature of sanitary pads (biodegradable or nonbiodegradable) used. The unmet needs associated with MMMs (menstrual cups and tampons) were significantly lower than that for other MHMs (including sanitary pads), in particular, the unmet material and home environment needs, unmet material reliability concerns, unmet reuse needs and unmet reuse insecurity. However, we found no significant difference between MMMs, sanitary pads and other MHMs in terms of unmet transport, college environment, change and disposal insecurity needs. The significant predictors of use of MMMs were age (more than 21 years of age), residence (urban), type of stay (off campus including home), socioeconomic status (upper), fathers' and mothers' education (high school and above), and presence of personal income. Discussions with friends (or peers) both before and after menarche regarding menstruation resulted in higher adoption of modern menstrual methods. CONCLUSION MMMs provided comparative advantage with lesser unmet needs for material reliability and reuse insecurity concerns, particularly in home environment. However, none of the MHMs fulfilled the user expectations for transport and disposal insecurity concerns, particularly outdoors.
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Affiliation(s)
- Thavansree Durairaj
- KMCH Institute of Health Sciences and Research, Coimbatore, Tamil Nadu, India
| | - Periasamy Aparnavi
- Department of Community Medicine, KMCH Institute of Health Sciences and Research, Coimbatore, Tamil Nadu, India
| | - Seetharaman Narayanan
- Department of Community Medicine, KMCH Institute of Health Sciences and Research, Coimbatore, Tamil Nadu, India
| | - Sushmitha Mahantshetti
- Department of Community Medicine, KMCH Institute of Health Sciences and Research, Coimbatore, Tamil Nadu, India
| | - Srihari Dhandapani
- Department of Community Medicine, KMCH Institute of Health Sciences and Research, Coimbatore, Tamil Nadu, India
| | - Jeevithan Shanmugam
- Department of Community Medicine, KMCH Institute of Health Sciences and Research, Coimbatore, Tamil Nadu, India
| | - Ramesh Rathinamoorthy
- Department of Community Medicine, KMCH Institute of Health Sciences and Research, Coimbatore, Tamil Nadu, India
| | - Mohan Kumar
- Department of Community Medicine, KMCH Institute of Health Sciences and Research, Coimbatore, Tamil Nadu, India.
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Walser SA, Costigan H, Stuckey HL, Berg A, Stephens MB. The Opaque Language of Sexuality: Medical Students' and Providers' Beliefs About Virginity. ARCHIVES OF SEXUAL BEHAVIOR 2023; 52:2619-2638. [PMID: 37039944 DOI: 10.1007/s10508-023-02578-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 02/28/2023] [Accepted: 02/28/2023] [Indexed: 06/19/2023]
Abstract
Although virginity is not a medical term and is instead socially constructed, it remains unknown what medical providers believe about the biological basis of virginity. This study explored providers' and medical students' beliefs about virginity and the potential impact of such beliefs on healthcare. This was a concurrent mixed-method survey study of 124 medical students and 216 healthcare providers (Registered Nurse, Physician Assistant, Nurse Practitioner, and Doctor of Medicine) at Penn State Health and The Pennsylvania State University College of Medicine. Participants rated their level of agreement with common misconceptions about virginity on a six-point Likert scale. Open-ended questions gave respondents the opportunity to define virginity and to describe terms like virgin and virginal in the context of sexual experience and the medical lexicon. We identified common themes in the qualitative data using thematic analysis. Frequencies of misconceptions and statistically significant demographic associations were identified in the quantitative data. Definitions of virginity were varied and vague, most with negative connotations. A majority of respondents said that virginity has no biological basis. Many participants identified downsides to use of terms like virgin, virginity, and virginal in medicine. The most prevalent misconceptions about virginity were related to the hymen. Seventeen percent of students and 26% of providers at least somewhat agreed that it was possible to determine whether a person has engaged in vaginal intercourse through a gynecological exam. Misconceptions about virginity persist in medicine and bias, even if unintended, may impact the quality-of-care people with vaginas receive. Language around sexual health should be specific, inclusive, clinically relevant, and free from judgment. Medical education must continue to work to eliminate the concept of a biological basis to virginity.
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Affiliation(s)
- Sarah A Walser
- The Pennsylvania State University College of Medicine, University Park Regional Campus, 1850 East Park Ave., State College, PA, 16801, USA.
| | - Heather Costigan
- Department of Humanities and Public Health Sciences, The Pennsylvania State University College of Medicine, Hershey, PA, USA
| | - Heather L Stuckey
- Department of Humanities and Public Health Sciences, The Pennsylvania State University College of Medicine, Hershey, PA, USA
| | - Arthur Berg
- Department of Public Health Sciences, The Pennsylvania State University College of Medicine, Hershey, PA, USA
| | - Mark B Stephens
- Department of Family and Community Medicine, The Pennsylvania State University College of Medicine, University Park Regional Campus, State College, PA, USA
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Roxanne Rahnejat K, Narice BF. Assessing menstrual equity amongst BAMER women fleeing gender-based abuse in Sheffield (UK): A cross-sectional study. SEXUAL & REPRODUCTIVE HEALTHCARE 2023; 35:100813. [PMID: 36709721 DOI: 10.1016/j.srhc.2023.100813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 01/04/2023] [Accepted: 01/18/2023] [Indexed: 01/22/2023]
Abstract
OBJECTIVES Menstruation is not openly discussed in numerous Black, Asian, minority ethnic and refugee (BAMER) communities. Consequently, it is unclear if transitioning between cultures impacts BAMER women's menstrual health. This study aimed to evaluate menstrual equity and sanitary protection preference amongst BAMER abuse survivors displaced to Sheffield (UK). METHODS Fifty participants were recruited from women's support services between December 2018 and May 2019. Selection criteria required participants to menstruate, identify as BAMER, be displaced, and have experienced gender-based abuse. Descriptive and inferential statistical analyses were performed using SPSS (IBM, USA) to assess menstrual equity. RESULTS Many struggled to afford products (86 %), changed them infrequently (68 %) or improvised sanitary wear (40 %). Financially restricted women often changed products irregularly (p = 0.02) or used proxy items (p = 0.02). Participants disliked reusable pads (48 %) and vaginally inserted products (tampons 46 %, cups 78 %) without having tried them. Negativity surrounding reusable pads (p = 0.01) and cups (p = 0.04) was linked to menstrual taboo. Few women knew of menstruation prior to menarche (28 %). These participants were more likely to accept male doctors (p = 0.04), unlike those that regarded menstruation as taboo (p = 0.02), unclean (p = 0.02) or shameful (p = 0.001). CONCLUSION We provide key information regarding the menstrual health status of marginalised women. Our findings suggest limited menstrual-health education at menarche and negative belief-systems may compromise access to products and healthcare in adulthood. This study advises policymakers to unify distribution of hygienic absorbents and menstrual-health education to normalise menstruation, thereby reducing menstrual shame and empowering women to make informed sanitary protective choices.
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Affiliation(s)
| | - Brenda F Narice
- NIHR Academic Clinical Lecturer, University of Sheffield, Obstetrics & Gynaecology, Jessop Wing Maternity Unit, Tree Root Walk, Sheffield S10 2SF, UK.
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Mohammed HS, A Sobh AM, Ibrahim ZM, Lotfy M. Evaluation of knowledge and practice of hymenoplasty among Egyptian gynaecologists: a cross-sectional study. EUR J CONTRACEP REPR 2021; 27:180-183. [PMID: 34860141 DOI: 10.1080/13625187.2021.2010039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVES The aims of the study were to evaluate the knowledge and practice of hymenoplasty among gynaecologists in Egypt. METHODS A cross-sectional study was conducted in January 2020, in which a self-administered questionnaire was completed by 120 gynaecologists at private clinics and hospitals in Ismailia, Egypt. The questionnaire consisted of 19 items relating to participants' sociodemographic characteristics, knowledge and practice of hymenoplasty. RESULTS Eighty-eight (73.3%) participants were not able to give an accurate definition of the hymen; furthermore, 65 (54.2%) were not aware of the different types of hymen. Forty-nine (40.8%) participants were able to define hymenoplasty and 39 (32.5%) knew the different hymenoplasty procedures. Hymenoplasty had been performed by 35 (29.2%) participants. Of these, 26 (74.3%) had carried out the procedure in a private clinic; the median annual number of procedures performed was four. Only two (5.7%) participants reported the occurrence of complications during the procedure. There were no sociodemographic differences between gynaecologists who had and had not performed hymenoplasty. CONCLUSION There is a lack of sufficient knowledge about hymenoplasty among Egyptian gynaecologists; nevertheless, it continues to be practised in private clinics.
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Affiliation(s)
- Heba Saber Mohammed
- Department of Obstetrics and Gynaecology, Faculty of Medicine, Suez Canal University, Ismailia, Egypt
| | - Ahmed M A Sobh
- Department of Obstetrics and Gynaecology, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Zakia M Ibrahim
- Department of Obstetrics and Gynaecology, Faculty of Medicine, Suez Canal University, Ismailia, Egypt
| | - Mariam Lotfy
- Department of Obstetrics and Gynaecology, Faculty of Medicine, Suez Canal University, Ismailia, Egypt
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Lejeune J, Martrille L, Guillet-May F, Marchand E. [Prospective forensic study on the characterization of genital examination in women with consented sexual activity]. ACTA ACUST UNITED AC 2021; 50:261-265. [PMID: 34715381 DOI: 10.1016/j.gofs.2021.10.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE The number of women victims of sexual assault remains high, despite prevention and information campaigns. These victims can be adolescent girls, women of childbearing age or postmenopausal women. As part of examinations of victims of sexual assault, the morpho-anatomical diversity of the female genitalia requires knowledge of the physiological variations existing by the practitioners caring for these victims. Our work aimed to describe and characterize the genital examination of women with consented sexual activity. METHOD Our cohort consisted of 196 women aged 14 to 81, examined in the context of medical gynecology consultations in two French maternity hospitals. RESULTS Recent genital traumatic injuries were found in 12.8% of women whose last sexual intercourse was less than 5 days old. Intact hymens, free from traumatic tearing despite regular sexual activity, were present in 10.7% of these women. CONCLUSION Thus, in many cases, genital examination alone cannot confirm or deny the existence of prior sexual intercourse, whether or not it was consented to. The development of work on data on female genital anatomy would make it possible to optimize the medico legal care of victims of sexual assault.
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Affiliation(s)
- J Lejeune
- Université de Lorraine, CHU Nancy, Service de Médecine Légale, F-54000 Nancy, France
| | - L Martrille
- Université de Lorraine, CHU Nancy, Service de Médecine Légale, F-54000 Nancy, France
| | - F Guillet-May
- CHU Nancy, Service de Médecine Légale, F-54000 Nancy, France
| | - E Marchand
- Université de Lorraine, CHU Nancy, Service de Médecine Légale, F-54000 Nancy, France.
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Garfield GB, Schou MP, Lassen K, Leth PM. Hymenal transections in children found by photocolposcopy in suspected sexual abuse cases is associated with a history of bleeding. J Forensic Leg Med 2021; 80:102176. [PMID: 33975177 DOI: 10.1016/j.jflm.2021.102176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 04/21/2021] [Accepted: 04/21/2021] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To investigate the difference in selected variables between children with and without hymenal transection, which is a healed defect that extends through the entire depth of the posterior hymenal membrane to the vaginal wall. MATERIALS AND METHODS All female children from Southern Denmark who were examined by photocolposcopy in a six-year period were included in a retrospective cohort study. Statistical analyses included a chi-square test and a logistic regression analysis. RESULTS Eighty girls under 15 years of age who were suspected to have been sexually abused were included. Sixteen of the girls had hymenal transections. There was a statistically significant correlation between the presence of hymenal transections and reported fresh bleeding after the assault. CONCLUSION Bleeding after an assault could indicate more severe lesions, which might explain why these patients did not heal completely.
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Affiliation(s)
- Gitte Bech Garfield
- Department of Forensic Medicine, University of Southern Denmark, J.B.Winsløws Vej 17B, 5000 Odense C, Denmark
| | - Mette Pagh Schou
- Department of Forensic Medicine, University of Southern Denmark, J.B.Winsløws Vej 17B, 5000 Odense C, Denmark
| | - Karin Lassen
- Department of Forensic Medicine, University of Southern Denmark, J.B.Winsløws Vej 17B, 5000 Odense C, Denmark
| | - Peter Mygind Leth
- Department of Forensic Medicine, University of Southern Denmark, J.B.Winsløws Vej 17B, 5000 Odense C, Denmark.
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Moaddab A, McCullough LB, Chervenak FA, Dildy GA, Shamshirsaz AA. Virginity testing in professional obstetric and gynaecological ethics. Lancet 2016; 388:98-100. [PMID: 26725366 DOI: 10.1016/s0140-6736(15)01275-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Affiliation(s)
- Amirhossein Moaddab
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, USA
| | - Laurence B McCullough
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, TX, USA.
| | - Frank A Chervenak
- Department of Obstetrics and Gynecology, Weill Medical College of Cornell University/New York Presbyterian Hospital, New York, NY, USA
| | - Gary A Dildy
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, USA
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Abstract
Hymenoplasty is a controversial surgery in Iran, where a woman's failure to present herself as virginal for marriage may result in severe social repercussions. Critical literature surrounding this clandestine surgery is sparse. During ethnographic fieldwork in Tehran, I interviewed women who have and have not undergone hymenoplasty and physicians who perform it. Using a Foucauldian framework, I argue that the medicalization of virginity is a form of female social control in Iran. The resulting narratives and discourses suggest that hymenoplasty is a covert form of resistance against socioculturally prescribed sexual inegalitarianism that restricts women to the social sphere of premarital chastity. By manipulating the medicalization of virginity, women inadvertently resist dichotomous gendered classifications that constrain them as either the deviant woman who has premarital sex or the normal woman who remains virginal until marriage. These women deviate from a fixed notion of gender embodiment, eroding socioculturally constituted categorical boundary markers regarding femininity.
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Affiliation(s)
- Azal Ahmadi
- Institute of Social and Cultural Anthropology, The University of Oxford and The Department of International Health, The Johns Hopkins Bloomberg School of Public Health.
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van Eijk AM, Sivakami M, Thakkar MB, Bauman A, Laserson KF, Coates S, Phillips-Howard PA. Menstrual hygiene management among adolescent girls in India: a systematic review and meta-analysis. BMJ Open 2016; 6:e010290. [PMID: 26936906 PMCID: PMC4785312 DOI: 10.1136/bmjopen-2015-010290] [Citation(s) in RCA: 132] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
OBJECTIVES To assess the status of menstrual hygiene management (MHM) among adolescent girls in India to determine unmet needs. DESIGN Systematic review and meta-analysis. We searched PubMed, The Global Health Database, Google Scholar and references for studies published from 2000 to September 2015 on girls' MHM. SETTING India. PARTICIPANTS Adolescent girls. OUTCOME MEASURES Information on menarche awareness, type of absorbent used, disposal, hygiene, restrictions and school absenteeism was extracted from eligible materials; a quality score was applied. Meta-analysis was used to estimate pooled prevalence (PP), and meta-regression to examine the effect of setting, region and time. RESULTS Data from 138 studies involving 193 subpopulations and 97,070 girls were extracted. In 88 studies, half of the girls reported being informed prior to menarche (PP 48%, 95% CI 43% to 53%, I(2) 98.6%). Commercial pad use was more common among urban (PP 67%, 57% to 76%, I(2) 99.3%, n=38) than rural girls (PP 32%, 25% to 38%, I(2) 98.6%, n=56, p<0.0001), with use increasing over time (p<0.0001). Inappropriate disposal was common (PP 23%, 16% to 31%, I(2) 99.0%, n=34). Menstruating girls experienced many restrictions, especially for religious activities (PP 0.77, 0.71 to 0.83, I(2) 99.1%, n=67). A quarter (PP 24%, 19% to 30%, I(2) 98.5%, n=64) reported missing school during periods. A lower prevalence of absenteeism was associated with higher commercial pad use in univariate (p=0.023) but not in multivariate analysis when adjusted for region (p=0.232, n=53). Approximately a third of girls changed their absorbents in school facilities (PP 37%, 29% to 46%, I(2) 97.8%, n=17). Half of the girls' homes had a toilet (PP 51%, 36% to 67%, I(2) 99.4%, n=21). The quality of studies imposed limitations on analyses and the interpretation of results (mean score 3 on a scale of 0-7). CONCLUSIONS Strengthening of MHM programmes in India is needed. Education on awareness, access to hygienic absorbents and disposal of MHM items need to be addressed. TRIAL REGISTRATION NUMBER CRD42015019197.
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Affiliation(s)
- Anna Maria van Eijk
- Department of Clinical Sciences, Liverpool school of Tropical Medicine, Liverpool, UK
| | - M Sivakami
- Tata Institute of Social Sciences, School of Health Systems Studies, Mumbai, Maharashtra, India
| | | | - Ashley Bauman
- Department of Clinical Sciences, Liverpool school of Tropical Medicine, Liverpool, UK
| | - Kayla F Laserson
- Centers for Disease Control and Prevention (CDC) India, Atlanta, Georgia, USA
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[Practical guide to the examination and interpretation of genital lesions of minor female victims of sexual assault]. ACTA ACUST UNITED AC 2014; 42:849-55. [PMID: 25458807 DOI: 10.1016/j.gyobfe.2014.10.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2013] [Accepted: 09/24/2014] [Indexed: 11/22/2022]
Abstract
Through a comprehensive review of the literature on sexual assault, the authors propose to clarify the different stages of the exam and help the practitioner to the forensic interpretation of lesions. The authors describe the basic principles that make consensus in how to interview victims in order to increase the reliability of the information collected. The various medical data that must be collected allowing to guide diagnosis (urogenital symptoms, sexual behaviour disorder) or facilitate the interpretation of lesions (age of puberty, use of tampons…) are specified as well as the different positions of examination and their association to other complementary techniques (Foley catheter, colposcopy, toluidine blue). The authors present a simple decision tree that can help the practitioner to interpret the laceration of the hymen. They detail the description and forensic interpretation of all genital lesions that may be encountered as a result of sexual assault, and the pitfalls to avoid. Finally, two main problems in the interpretation of lesions are described, the absence of injury after penetration and the accidental genital lesions.
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Watrowski R, Jäger C, Gerber M, Klein C. Hymenal anomalies in twins--review of the literature and case report. Eur J Pediatr 2014; 173:1407-12. [PMID: 23933671 DOI: 10.1007/s00431-013-2123-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2013] [Revised: 07/21/2013] [Accepted: 07/25/2013] [Indexed: 01/18/2023]
Abstract
UNLABELLED Subocclusive hymenal variants, such as microperforate or septate hymen, impair somatic functions (e.g., vaginal intercourse or menstrual hygiene) and can negatively impact the quality of life of young women. We know little about the prevalence and inheritance of subocclusive hymenal variants. So far, eight cases of familial occurrence of occlusive hymenal anomalies (imperforate hymen) have been reported. In one of these cases, monozygotic twins were affected. We are reporting the first case of subocclusive hymenal variants (microperforate hymen and septate hymen) in 16-year-old white dizygotic twins. In addition, we review and discuss the current evidence. CONCLUSION The mode of inheritance of hymenal variants has not been determined so far. Because surgical corrections of hymenal variants should be carried out in asymptomatic patients (before menarche), gynecologists and pediatricians should keep in mind that familial occurrences may occur.
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Affiliation(s)
- Rafal Watrowski
- Division of Gynecology and Obstetrics, St. Josefskrankenhaus, Academic Teaching Hospital of the University of Freiburg, Sautierstr.1, 79104, Freiburg, Germany,
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Farage MA, Miller KW, Davis A. Cultural aspects of menstruation and menstrual hygiene in adolescents. ACTA ACUST UNITED AC 2014. [DOI: 10.1586/eog.11.1] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Tschudin S, Schuster S, Dumont dos Santos D, Huang D, Bitzer J, Leeners B. Restoration of virginity: women's demand and health care providers' response in Switzerland. J Sex Med 2013; 10:2334-42. [PMID: 23809541 DOI: 10.1111/jsm.12231] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
INTRODUCTION As a result of transnational migration, health institutions are faced with growing demand for "restoration" of virginity. The practice of hymen reconstruction constitutes a challenge for health care providers in medical, ethical, judicial, social, and cultural dimensions, for which they are not well prepared. AIM The aim of the presented nationwide survey was to investigate the experience of Swiss gynecologists with women requesting hymen reconstruction. METHODS A questionnaire specifically designed for this purpose was sent to 100 public hospitals. MAIN OUTCOME MEASURES Main outcome measures included demands for (number of requests, origin of women) and attitudes toward hymen reconstruction (requests granted, decision-making for or against intervention, surgical technique applied, problems associated with the requests for hymen repair, cost coverage, need for further information) in Switzerland. RESULTS The response rate was 68%. Of the 43 clinics (63.2%) confronted with requests for hymen reconstruction, 38 (90.5%) claimed to see up to five patients per year. The predominantly mentioned countries of origin were Turkey in the German-speaking part and Arab countries in the French-speaking part. More than half of the clinics (27/64.3%) reported that they always (12/28.6%) or mostly (15/35.7%) granted the request. Decision for surgery was made after intensive counseling in 44.2% and on demand of the patient after brief counseling in 32.7%. The so-called approximation method was the most frequently applied surgical technique. A third of the participants (19/35.2%) reported problems with confidentiality. More than half of the clinics expressed their need for further information on this topic. CONCLUSIONS Hymen reconstruction is rarely performed in Switzerland, even though two-thirds of the responding hospitals are confronted with this issue several times per year. No guidelines exist on how health professionals should deal with these requests. Interdisciplinary research on how to meet the needs of women and health care providers in such cross-cultural encounters is needed.
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Affiliation(s)
- Sibil Tschudin
- Department of Obstetrics and Gynecology, University Hospital Basel, Basel, Switzerland
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van Moorst BR, van Lunsen RHW, van Dijken DKE, Salvatore CM. Backgrounds of women applying for hymen reconstruction, the effects of counselling on myths and misunderstandings about virginity, and the results of hymen reconstruction. EUR J CONTRACEP REPR 2012; 17:93-105. [PMID: 22292534 DOI: 10.3109/13625187.2011.649866] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
ABSTRACT Objective To study the backgrounds of women requesting hymen 'repair', to assess the effects of extensive counselling, and the effects of hymen reconstruction. Methods A two-centre qualitative study, consisting of a semi-structured interview, education, discussion of alternatives, and instructions for self-examination (first visit), educational examination (second visit), decision on operation or alternative (third visit), and follow-up (fourth visit). Results Eighty-two women were interviewed at first visit. Sixty-eight women were followed until their decision to be operated upon or not. Forty-eight percent of all subjects reported a history of sexual violence, and 37% had had one or more abortions. Only 29% eventually decided to be operated. Seventeen of the 19 women who submitted to an operation and attended the follow-up visit reported no blood loss at first marital intercourse. Conclusions Most women requesting hymen reconstruction had a history complicated by critical life events related to their request. All women were afraid they would not bleed and/or would not be 'tight' enough during the wedding night. For 75% of the women empowerment by means of extensive counselling resulted in a decision against operation. Hymenoplasty alone does not help women because most operated women will not bleed and because they often also have to prove to be 'tight' enough.
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Affiliation(s)
- Bianca R van Moorst
- Department of Obstetrics and Gynaecology, St Lucas/Andreas Hospital, Amsterdam, the Netherlands
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Stewart ST. Hymenal characteristics in girls with and without a history of sexual abuse. JOURNAL OF CHILD SEXUAL ABUSE 2011; 20:521-536. [PMID: 21970644 DOI: 10.1080/10538712.2011.606106] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
This article reviews the recent literature on physical findings related to the hymen in pubertal and prepubertal girls with and without a history of sexual abuse. Characteristics of normal hymenal anatomy, acute traumatic findings, and characteristics of healed trauma are discussed, particularly with regard to changes in the interpretation of these findings that have occurred over time.
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Affiliation(s)
- Sara T Stewart
- Child Crisis Center, Harbor-UCLA Medical Center, Torrance, California 90509, USA.
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Adams JA. Medical evaluation of suspected child sexual abuse: 2011 update. JOURNAL OF CHILD SEXUAL ABUSE 2011; 20:588-605. [PMID: 21970647 DOI: 10.1080/10538712.2011.606107] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
The medical evaluation of children with suspected sexual abuse includes more than just the physical examination of the child. The importance of taking a detailed medical history from the parents and a history from the child about physical sensations following sexual contact has been emphasized in other articles in the medical literature. The examination is important, however, and medical providers who examine children need to be aware of published research on findings in nonabused children, studies of healing of injuries, and studies documenting the association between sexual contact and the diagnosis of sexually transmissible infections in children. This article reviews the current approach to interpreting findings in children who may have been sexually abused and why additional research is needed.
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Affiliation(s)
- Joyce A Adams
- University of California, San Diego School of Medicine, San Diego, California 92123, USA.
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Essén B, Blomkvist A, Helström L, Johnsdotter S. The experience and responses of Swedish health professionals to patients requesting virginity restoration (hymen repair). REPRODUCTIVE HEALTH MATTERS 2010; 18:38-46. [PMID: 20541082 DOI: 10.1016/s0968-8080(10)35498-x] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
An important determinant of family honour in many cultures is the chastity of women, with much importance attributed to virginity until marriage. The traditional proof of virginity is bleeding from the ruptured hymen, which has led some women to request genital surgery to "restore" virginity, or hymen repair. The aim of this study was to investigate whether Swedish health care providers have had experience of patients requesting this surgery. Questionnaires were sent to 1,086 gynaecologists, midwives, youth welfare and social officers, and school nurses and doctors in four Swedish cities. Of the 507 who returned the questionnaire, 271 had seen patients seeking virginity-related care. Of these, 14 had turned the patients away; 221 had made 429 referrals, mostly to a welfare officer or a gynaecologist; and 26 had referred patients to a plastic surgeon. Nine gynaecologists had carried out such surgery themselves. Swedish authorities have to date focused on this issue primarily from a social and legal perspective. No guidelines exist on how health professionals should deal with requests for surgery to restore virginity. Further research is needed on how best to meet the needs of this group of patients in a multi-ethnic society and how to address requests for hymen repair. Without this, medical practitioners and counsellors will remain uncertain and ambivalent, and a variety of approaches will persist.
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Affiliation(s)
- Birgitta Essén
- Department of Women's and Children's Health, International Maternal and Child Health, Uppsala University, Sweden.
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Changes in genital anatomy and microbiology in girls between age 6 and age 12 years: a longitudinal study. J Pediatr Adolesc Gynecol 2010; 23:77-85. [PMID: 19643638 DOI: 10.1016/j.jpag.2009.05.012] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2008] [Revised: 05/22/2009] [Accepted: 05/28/2009] [Indexed: 11/24/2022]
Abstract
STUDY OBJECTIVE To study changes in genital anatomy and occurrence of human papillomavirus and Gardnerella vaginalis in girls resulting from growth and development. DESIGN At age 11-12 years, an invitation was sent to 180 girls to attend a follow-up examination. All girls had previously participated in a study exploring anogenital anatomy and microbiology in children selected for non-abuse at age 5 and 6. The genital area was examined with a colposcope and microbiological samples for Gardnerella vaginalis (GV) and human papillomavirus (HPV) were collected. GV was identified by conventional criteria and HPV by a PCR method. RESULTS Thirty-one girls were examined twice, at mean age 5.7 and 12.0 years. At first examination all were pre-pubertal. At second examination 21 girls were B2/P2 or above. Significantly more girls had developed a structure called a fossa groove. A thick and redundant hymen with a tendency of folding outward was more common at the second examination. Two girls had GV and one girl had HPV-16 identified. Another girl was classified to have a deep notch and a probable transection in her hymen, and this girl reported a painful insertion of a tampon. All girls denied sexual activity. CONCLUSION The main genital finding in girls entering puberty is the hymen becoming thick and redundant with a tendency of folding out. In the study findings associated with sexual activity were discovered in two girls, and the possibility of alternative explanations is discussed.
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Report of the FIGO Working Group on Sexual Violence/HIV: Guidelines for the management of female survivors of sexual assault. Int J Gynaecol Obstet 2010; 109:85-92. [DOI: 10.1016/j.ijgo.2010.02.001] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Fatton B, Savary D, Accoceberry M, Velemir L, Amblard J, Jacquetin B. Chirurgie sexuelle chez la femme. ACTA ACUST UNITED AC 2008. [DOI: 10.1007/s11608-008-0195-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Pillai M. An evaluation of ‘confirmatory’ medical opinion given to English courts in 14 cases of alleged child sexual abuse. J Forensic Leg Med 2007; 14:503-14. [DOI: 10.1016/j.jflm.2006.11.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2006] [Revised: 11/29/2006] [Accepted: 11/30/2006] [Indexed: 10/23/2022]
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Adams JA, Kaplan RA, Starling SP, Mehta NH, Finkel MA, Botash AS, Kellogg ND, Shapiro RA. Guidelines for medical care of children who may have been sexually abused. J Pediatr Adolesc Gynecol 2007; 20:163-72. [PMID: 17561184 DOI: 10.1016/j.jpag.2006.10.001] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2006] [Revised: 09/02/2006] [Indexed: 10/23/2022]
Abstract
BACKGROUND Children who may have been sexually abused are examined in many different settings by medical providers with variable levels of education and experience in this special area of practice. Therefore, there is a need for a consistent evidence-based approach that is agreed upon by medical experts. OBJECTIVES To develop and provide guidelines and recommendations for performing and interpreting findings of the medical evaluation of children referred for sexual abuse medical evaluations, and to provide guidelines for the education, oversight, and peer review process for clinicians who provide assessments for suspected child sexual abuse. METHODS Participation from medical providers was solicited through postings on the Internet list-serves administered by Cornell University (Special Interest Group in Child Abuse), and by the Ray E. Helfer Society, an honorary society for physician specialists in child abuse diagnosis and treatment. The guidelines were developed through review and critique of published research studies, discussions in focus group meetings at child abuse medical conferences, and ongoing communication leading to revision of draft documents. RESULTS Groups of 10 to 40 physician experts met at child abuse conferences between January 2002 and January 2005 to revise the table summarizing the interpretation of physical and laboratory findings in suspected child sexual abuse and to develop guidelines for medical care for sexually abused children. Between January and December 2005, the guidelines were expanded and revised. CONCLUSIONS The guidelines presented here reflect the current knowledge, recommended clinical approaches, and required competencies in the field of child sexual abuse medical evaluation.
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Affiliation(s)
- Joyce A Adams
- University of California, San Diego School of Medicine, San Diego, California 92103, USA.
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Goodman MP, Bachmann G, Johnson C, Fourcroy JL, Goldstein A, Goldstein G, Sklar S. Controversies in Sexual Medicine: Is Elective Vulvar Plastic Surgery Ever Warranted, and What Screening Should Be Conducted Preoperatively? J Sex Med 2007; 4:269-76. [PMID: 17367421 DOI: 10.1111/j.1743-6109.2007.00431.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Elective vulvar plastic surgery was the topic of a heated discussion on the list-serve of the International Society for the Study of Women's Sexual Medicine. At the suggestion of a board member, it was determined that this discussion might of interest to journal readers in the form of a published controversy. METHODS Six people with expertise and/or strong opinions in the area of vulvar health, several of whom had been involved in the earlier online discussion, were invited to submit evidence-based opinions on the topic. MAIN OUTCOME MEASURE To provide food for thought, discussion, and possible further research in a poorly discussed area of sexual medicine. RESULTS Goodman believes that patients should make their own decisions. Bachmann further states that, while that is a woman's right, she should be counseled first, because variations in looks of the vulvar region are normal. Johnson furthers this thought, discussing the requirement for counseling before performing reinfibulation surgery on victims of female genital cutting. Fourcroy emphasizes the need to base surgical procedures on safety and efficacy in the long term, and not merely opportunity at the moment. Goldstein and Goldstein state that, based on the four principles of ethical practice of medicine, vulvar plastic surgery is not always ethical, but not always unethical. Sklar pursues this thought further, pointing out specific examples in regard to the principles of ethics. CONCLUSION Vulvar plastic surgery may be warranted only after counseling if it is still the patient's preference, provided that it is conducted in a safe manner and not solely for the purpose of performing surgery.
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Bramante M. Genital Hygiene. THE VULVA 2006:183-216. [DOI: 10.1201/9781420005318-13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
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Abstract
Stories about sexual activity abound and are often the source of considerable interest and speculation. These anecdotal accounts are rarely subjected to any serious scrutiny and yet may develop folklore proportions. It is concerning that many forensic practitioners are prepared to perpetuate similar myths behind a veneer of scientific practice. Practices such as impotence or virginity testing and the interpretation of penile measurements are lucrative endeavors that remain alive and well. Similarly, court evidence on topics such as the circumstances by which genital injuries were sustained, the relationship between pubertal staging and age or the interpretation of anal findings are often less than objective. These practices are unprofessional. Further, they have the potential to cause significant harm to many individuals and to undermine the standing of the criminal justice system.
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Affiliation(s)
- David L Wells
- Victorian Institute of Forensic Medicine, 57-83 Kavanagh Street, Southbank, 3006 Victoria, Australia.
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Affiliation(s)
- Joyce A Adams
- Department of Pediatrics, University of California Medical Center, University of California, San Diego, California 92103-8449, USA.
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Kellogg ND, Menard SW, Santos A. Genital anatomy in pregnant adolescents: "normal" does not mean "nothing happened". Pediatrics 2004; 113:e67-9. [PMID: 14702498 DOI: 10.1542/peds.113.1.e67] [Citation(s) in RCA: 110] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Many clinicians expect that a history of penile-vaginal penetration will be associated with examination findings of penetrating trauma. A retrospective case review of 36 pregnant adolescent girls who presented for sexual abuse evaluations was performed to determine the presence or absence of genital findings that indicate penetrating trauma. Historical information and photograph documentation were reviewed. Only 2 of the 36 subjects had definitive findings of penetration. This study may be helpful in assisting clinicians and juries to understand that vaginal penetration generally does not result in observable evidence of healed injury to perihymenal tissues.
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Affiliation(s)
- Nancy D Kellogg
- Departments of Pediatrics, University of Texas Health Science Center, San Antonio 78229, USA.
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Lincoln C. Genital injury: is it significant? A review of the literature. MEDICINE, SCIENCE, AND THE LAW 2001; 41:206-216. [PMID: 11506344 DOI: 10.1177/002580240104100303] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
The purpose of this review was to critically evaluate the available literature on genital injury in order to facilitate an understanding of its significance in relation to sexual offence trials. Wide variation exists in research objectives, study populations and methodology, hindering interpretation considerably. The most valuable research in this field identifies the range of normal genital findings and those associated with consensual sexual intercourse, to enable interpretation of genital findings in sexual assault victims. However, there are, unfortunately, few studies of this nature. Difficulties arise when examining doctors are not experienced in the genital examination of those other than sexual assault victims, limiting their ability to draw conclusions about genital injury if it is detected. If the methods of genital examination employed are not the same as those used to examine a wide range of non-sexual assault victims, comparison and thus valuable interpretation is further limited. This review of the literature finds that the most appropriate genital examinations and indeed the most legally valuable as far as interpretation is concerned, are done macroscopically by doctors with considerable experience in the examination of normal, diseased and traumatized genitalia, and a sound knowledge of the principles of injury interpretation. A deficiency exists in the literature in relation to macroscopic genital examination findings in consensually sexually active women who have been examined by forensically trained doctors. This deficiency must be addressed before the medicolegal significance of genital injury relating to sexual assault can be accurately interpreted, and before any decision is made to incorporate colposcopy or staining techniques into the routine assessment of sexual assault victims.
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Affiliation(s)
- C Lincoln
- Medical and Forensic Services, Sexual Assault Resource Centre, Perth, Western Australia
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Kellogg ND, Lamb JL, Lukefahr JL. The use of telemedicine in child sexual abuse evaluations. CHILD ABUSE & NEGLECT 2000; 24:1601-1612. [PMID: 11197038 DOI: 10.1016/s0145-2134(00)00204-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
OBJECTIVE To describe the advantages, disadvantages and current status of child abuse consultations conducted through telemedicine networks. METHOD The results of a telephone survey of seven statewide telemedicine networks are reported and discussed with respect to goals, funding, technical support and expertise, infrastructure, and extent of use. Quality assurance and liability issues concerning telemedicine child abuse consultations are also reviewed. RESULTS The goals of telemedicine networks in child abuse are to provide (1) expertise to less experienced clinicians primarily in rural areas; (2) a method for peer review and quality assurance to build consensus of opinions particularly in sexual abuse cases; and (3) support for professionals involved in an emotionally burdensome area of pediatrics. Problems encountered by existing networks include: (1) funding for equipment and reimbursement for consultation; (2) consistent technical support: (3) clinician lack of technical expertise, knowledge, or motivation; and (4) lack of network infrastructure. Legal considerations include licensure exemptions for consulting across state lines, potential for malpractice, patient confidentiality and security of images forwarded over modem lines, and liability of the equipment, consulting site, and the consultant in criminal proceedings. CONCLUSIONS Telemedicine consultations offer a unique opportunity to raise the standard of care in child abuse evaluations, but success depends on clinician motivation, appropriate infrastructure, and ongoing funding and technical support.
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Affiliation(s)
- N D Kellogg
- University of Texas Health Science Center at San Antonio, USA
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Edgardh K, von Krogh G, Ormstad K. Adolescent girls investigated for sexual abuse: history, physical findings and legal outcome. Forensic Sci Int 1999; 104:1-15. [PMID: 10533272 DOI: 10.1016/s0379-0738(99)00093-6] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The aim of the study was to summarize the history of assault and record the results of medicolegal examination in adolescent girls under investigation for alleged sexual abuse, and to monitor the outcome of the legal process. The investigation period was 1990-94. METHOD A consecutive series of 94 0-para girls, aged 9-22, median age 15.0 years, were examined in the head-to-toe manner including anogenital examination. Girls were referred from investigating police and social authorities. Only non-acute examinations were performed. Findings considered consistent with abusive vaginal penetration were hymenal distortion including deep clefts, hymenal and vestibular scarring, and introital diameter permitting vaginal inspection with a 17 mm speculum in the absence of consensual intercourse. Perianal scarring was recorded. STD sampling was made on indication. Findings were documented on body sketches. Medicolegal conclusions were grouped into three categories according to history and physical findings. Information on the outcome of legal procedures was collected from referring authorities. RESULTS For 82% (77/94) of the girls, referring agencies provided examining physicians with a detailed and consistent history of abuse, presented results comprise these 77 girls. Intrafamiliar abuse was alleged by 81% (62/77), onset prior to menarche by 53% (41/77), and repeated abuse by 74% (57/77) of the girls. Abusive genital penetration was reported by 77% (59/77) and anal penetration by 19% (14/77). Sequelae after admitted self-inflicted injury were found in 15% (12/77). Deep hymenal clefts and/or vestibular scars were found in 59% (35/59) of the girls reporting penetrative abuse, compared with 6% (1/16) when non-penetrative abuse was alleged, P < 0.001. Girls with experience of voluntary intercourse could all be examined with a 25 mm speculum. Of the 17 girls without experience of consensual intercourse but alleging abusive penetration, 47% (17/36) could easily be examined with a 17 mm speculum, compared to none of 13 reporting non-penetrative abuse, P < 0.001. Non-specific anal abnormalities occurred in 10 (13%) girls; more often when anal abuse was reported, P < 0.001. No specific STDs were found. The medicolegal conclusion supported a history of abusive genital penetration in 41 (69%) cases; findings were non-specific in 11 cases and a normal anogenital status was found in 25 cases. The alleged abuse of 34 of the 77 (44%) girls was tried in court. One suspect was acquitted, 32 men were convicted of the abuse of 33 girls. Eleven perpetrators admitted abuse, and their histories were in concordance with the abuse alleged by the victims, as well as with the physical findings. CONCLUSION A medicolegal diagnosis of alleged non-acute cases of sexual abuse relies on a detailed history. Adolescent girls alleging abuse may exhibit signs of admittedly self-inflicted extragenital injury. Our findings confirm that non-penetrative sexual acts leave no lasting genital signs, but that repeated abusive genital penetration significantly more often than non-penetrative abuse leaves deep posterior hymenal clefts and/or vestibular scarring, and a hymenal opening allowing examination with 17-25 mm specula also in girls without experience of voluntary intercourse. In cases with a confessing perpetrator, no discordance was found between the history of the victim, medicolegal conclusion and the history of the perpetrator.
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Affiliation(s)
- K Edgardh
- Venhälsan, Söder Hospital, Stockholm, Sweden
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Abstract
Three rape homicide cases and two cases of attempted rape homicide involving children investigated in the Bonn University Institute of Forensic Medicine from 1992 to 1996 are described in order to assess whether characteristic features were present. The victims were girls aged from 3 to 12 years old. At autopsy haematomas, contusions and/or lacerations of the external/internal genitalia or anus confirmed sexual assault. Extragenital injuries found in every case included bruises, haematomas, abrasions and incised wounds caused by resisting, to struggling and manual pressure or gripping. Each death was caused by manual or ligature strangulation. The evidential value of the anogenital injuries encountered at autopsy is discussed and compared with the physical signs found at clinical examination.
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Affiliation(s)
- P Schmidt
- Institute of Forensic Medicine, University of Bonn, Stifsplatz 12, D 53111 Bonn, Germany
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Muram D, Arheart KL, Jennings SG. Diagnostic accuracy of colposcopic photographs in child sexual abuse evaluations. J Pediatr Adolesc Gynecol 1999; 12:58-61. [PMID: 10326188 DOI: 10.1016/s1083-3188(00)86627-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
STUDY OBJECTIVE To evaluate the utility of colposcopic photographs in child sexual abuse evaluations and to assess whether such photographs can be reliably used for peer review, second opinion, and court testimony. METHODS A prospective review of colposcopic photographs at the Pediatric and Adolescent Gynecology Clinic in Louisville, Kentucky. Participants were 189 girls who were referred for evaluation for possible sexual abuse. Interventions used included gynecologic evaluation, colposcopic photographs, and review of photographs. The main outcome measure was the degree of agreement between the examining physician and the reviewers. RESULTS The reviewers' accuracy for the entire set of 189 cases is uniformly high (93%-95%). Accuracy rates are significantly lower for pubertal girls (83%-90%) and for girls with signs of abuse (58%-88%). CONCLUSIONS The diagnostic accuracy of the colposcopic photographs is sufficiently high to warrant continued use of medical photography for documentation and peer review. One should anticipate some disagreements between the examining physician and the reviewers, and contradictory opinions are more likely to occur with girls exhibiting physical signs of abuse and with pubertal girls.
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Affiliation(s)
- D Muram
- Department of Obstetrics and Gynecology, University of Tromsø, Norway
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Curtis E, San Lazaro C. Appearance of the hymen in adolescents is not well documented. BMJ (CLINICAL RESEARCH ED.) 1999; 318:605. [PMID: 10037658 PMCID: PMC1115047 DOI: 10.1136/bmj.318.7183.605] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Goodyear-Smith FA, Laidlaw TM. What is an 'intact' hymen? A critique of the literature. MEDICINE, SCIENCE, AND THE LAW 1998; 38:289-300. [PMID: 9808940 DOI: 10.1177/002580249803800404] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
Abstract
The purpose of this study was to establish medico-legal guidelines based upon medical findings which support or refute allegations of sexual penetration, taking into account non-sexual explanations for positive physical findings. A review of the literature was undertaken to examine what has been determined about the range of usual findings which can be expected if the hymen has been penetrated. While a large body of literature is available on the topic, some findings are ambiguous, and further research is required to advance and clarify our knowledge base in these areas. In only a minority of non-acute cases can definitive statements be made as to whether an alleged molestation has occurred. A non-scarred hymen that will not admit a finger is 'intact'; a hymenal opening accommodating two fingers or a vaginal speculum, with evidence of a deficit or scarring at the lower pole, indicates past sexual or, possibly, non-sexual penetration. Other findings are not definitive and, at best, can estimate only relative probability of occurrence of penetration. Findings within the normal range should be presented as 'neither confirm nor deny abuse', not 'consistent with abuse'. Often, it is impossible to establish whether a hymen is 'intact' in regard to past sexual intercourse.
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Affiliation(s)
- F A Goodyear-Smith
- Department of Psychiatry and Behavioural Science, Auckland Medical School, New Zealand
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Rogers DJ, Stark M. The hymen is not necessarily torn after sexual intercourse. BMJ (CLINICAL RESEARCH ED.) 1998; 317:414. [PMID: 9694770 PMCID: PMC1113684 DOI: 10.1136/bmj.317.7155.414] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Goodyear-Smith FA, Laidlaw TM. Can tampon use cause hymen changes in girls who have not had sexual intercourse? A review of the literature. Forensic Sci Int 1998; 94:147-53. [PMID: 9670493 DOI: 10.1016/s0379-0738(98)00053-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Since tampon availability has become ubiquitous, several authors have opined about their effect on the virginal hymen, but only one paper has scientifically addressed the subject of tampon use and clefts in the hymens of never-sexually-active adolescent girls. It naturally has become an authority used by the courts. The Emans et al. (1994) study asserts that 'for physicians testifying in court about sexual assault cases, complete clefts in adolescents cannot be attributed to prior tampon use'. On closer inspection, however, it appears that the authors have interpreted their statistical finding using a strict scientific convention (chi 2, P = 0.06 as not having statistical significance) that may mislead in a clinical or legal situation. Indeed, there is a definite possibility that tampon use compared to not having used tampons in their never-sexually-active sample was associated with an increased percentage of complete hymenal clefts (14% vs. 6%; P = 0.06). Nevertheless, clefts were found in both the sexually active and the never-active groups: 20 of their 200 never-sexually-active subjects possessed complete hymenal clefts, as did only 84 of their 100 sexually active subjects. Caution should be used by all physicians asked to testify in courts regarding possible causes of a hymenal cleft.
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Affiliation(s)
- F A Goodyear-Smith
- Department of Psychiatry and Behavioural Science, University of Auckland School of Medicine, New Zealand.
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Affiliation(s)
- A B Berenson
- Department of Obstetrics & Gynecology, University of Texas Medical Branch, Galveston, USA
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Abstract
In summary, child abuse requires a multidisciplinary approach. The clinician's role in obtaining the history and physical examination demands that one be familiar with interview technique, appropriate developmental milestones, normal genital anatomy, and the use of local community resources. Knowing that there are circumstances when the examination should be deferred to a specialized center or done under anesthesia is critical. Determining that a reasonable suspicion of abuse exists is the job of the clinician. The final determination of abuse is under the purview of the legal system.
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Affiliation(s)
- N Kini
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, USA
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Affiliation(s)
- J A Adams
- University of California, San Diego 92013-8449, USA
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Kini N, Brady WJ, Lazoritz S. Evaluating child sexual abuse in the emergency department: clinical and behavioral indicators. Acad Emerg Med 1996; 3:966-76. [PMID: 8891046 DOI: 10.1111/j.1553-2712.1996.tb03330.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Child sexual abuse is an increasingly common problem. This article reviews the current clinical and behavioral indicators that will aid the emergency physician when evaluating and managing this condition. The most common differential diagnoses are described and a general approach to this diagnosis is suggested. Adopting a multidisciplinary method when evaluating this problem will lessen the anxiety facing the examining physician and provide a better outcome for the child, parents, and community.
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Affiliation(s)
- N Kini
- Medical College of Wisconsin, Department of Pediatrics, Milwaukee 53226, USA.
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Abstract
The medical evidence, detailing the physical findings, is just one component in the investigation of serious sexual assault and it is not for the doctor alone to determine the veracity of an allegation. This paper has described some of the factors which limit the quality and value of the medical evidence. Potential ways to rectify the problems are: 1. A requirement that all doctors who examine complainants of sexual assault should have undergone basic theoretical and practical training and be required to continue their education by attendance at update meetings and participating in peer review groups. 2. Large-scale, well-designed research projects which relate the physical findings to the outcome of the case. 3. Routine colposcopic assessments with photo-documentation of the genital examinations of all complainants of serious sexual offences. 4. Pretrial debate amongst medical experts.
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Affiliation(s)
- D Rogers
- Clinical Forensic Medicine Section, Royal Society of Medicine
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Hobbs CJ, Wynne JM. Child sexual abuse--the interface with genitourinary medicine. Genitourin Med 1995; 71:334. [PMID: 7490062 PMCID: PMC1195561 DOI: 10.1136/sti.71.5.334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
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